Lumbar fusion versus nonoperative management for treatment of discogenic low back pain: a systematic review and meta-analysis of randomized controlled trials.

STUDY DESIGN: Systematic review and meta-analysis of randomized controlled trials (RCTs). OBJECTIVE: To evaluate the current evidence comparing lumbar fusion to nonoperative management for the treatment of chronic discogenic low back pain. BACKGROUND AND CONTEXT: Discogenic low back pain is a common and sometimes disabling condition. When the condition becomes chronic and intractable, spinal fusion may play a role. METHODS: A systematic review of the literature was conducted using the PubMed and CENTRAL databases. We included RCTs that compared lumbar fusion to nonoperative management for the treatment of adult patients with chronic discogenic low back pain. A meta-analysis was conducted to assess the improvement in back pain based on the Oswestry Disability Index (ODI). RESULTS: Five RCTs met our inclusion criteria. A total of 707 patients were divided into lumbar fusion (n=523) and conservative management (n=134). Although inclusion/exclusion criteria were relatively similar across studies, surgical techniques and conservative management protocols varied. The pooled mean difference in ODI (final ODI-initial ODI) between the nonoperative and lumbar fusion groups across all studies was -7.39 points (95% confidence interval: -20.26, 5.47) in favor of lumbar fusion, but this difference was not statistically significant (P=0.26). CONCLUSIONS: Despite the significant improvement in ODI in the lumbar fusion groups in 3 studies, pooled data revealed no significant difference when compared with the nonoperative group. Although there was an overall improvement of 7.39 points in the ODI in favor of lumbar fusion, it is unclear that this change in ODI would lead to a clinically significant difference. Prospective randomized trials comparing a specific surgical technique versus a structured physical therapy program may improve evidence quality. Until then, either operative intervention by lumbar fusion or nonoperative management and physical therapy remain 2 acceptable treatment methods for intractable low back pain.

Complications, reoperation rates, and health-care cost following surgical treatment of lumbar spondylolisthesis.

BACKGROUND: Surgery remains the mainstay for management of lumbar spondylolisthesis and is considered an effective therapeutic modality following unsuccessful nonoperative treatment. Surgical procedures include decompression, decompression with instrumented arthrodesis, and decompression with noninstrumented arthrodesis. The purpose of this study was to examine the complications, reoperation rates, and health-care costs associated with each of these procedures. METHODS: The MarketScan database was utilized to identify 16,556 patients with a primary diagnosis of lumbar spondylolisthesis who underwent surgical treatment from 2000 to 2009. Outcomes were evaluated in propensity score-matched cohorts, with complication rates analyzed with the chi-square test, reoperation rates analyzed using the Mantel-Haenszel test, and health-care resource use analyzed using the Wilcoxon signed-rank test. RESULTS: Complication rates were significantly higher in patients who underwent arthrodesis compared with those who had decompression alone during the initial hospitalization (8.3% versus 4.8%; p < 0.0001) and at the time of the ninety-day follow-up (9.6% versus 5.5%; p < 0.0001). Complication rates were similar for those who received instrumented and noninstrumented arthrodesis. Patients who underwent decompression alone had higher reoperation rates at two years or more than those who received arthrodesis (15.7% versus 11.9%; p = 0.034). Patients with instrumented arthrodesis trended to have higher reoperation rates than those without instrumentation at five years or more (18.4% versus 10.6%; p = 0.063). Initial hospital costs and two-year and five-year overall costs (in 2009 U.S. dollars) were higher for patients managed with arthrodesis than for those who had decompression only ($102,906 versus $89,337; p = 0.0018). Also, patients who received instrumentation had higher hospitalization costs than those without instrumentation ($39,997 versus $27,309; p = 0.023) and higher overall costs at two years ($73,482 versus $60,394; p < 0.0001), although the difference was not significant at five years (p = 0.29). CONCLUSIONS: Patients with lumbar spondylolisthesis who underwent decompressive laminectomy and spinal arthrodesis had lower reoperation rates but higher overall costs than patients treated with laminectomy alone. Noninstrumented arthrodesis was also associated with lower long-term reoperation rates and health-care costs compared with instrumented arthrodesis. The long-term outcomes and costs of these procedures should be evaluated in conjunction with clinical efficacy to ensure the most cost-effective treatment is utilized. LEVEL OF EVIDENCE: Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes in patients with minimal back pain undergoing prophylactic lumbar fusion for iatrogenic instability.

For most patients undergoing lumbar fusion, back pain is a substantial part of their preoperative symptomatology. Occasionally, there are patients with minimal back pain in whom the extent of decompression required to treat leg symptoms requires a concomitant fusion to prevent postoperative instability. Although these patients may obtain relief of their leg pain, an additional concern is whether they will develop increased back pain after fusion. This study's primary cohort comprised 1144 patients with complete preoperative and 2-year postoperative data including the Oswestry Disability Index (ODI), Short Form 36 (SF-36), and numeric rating scales (NRS) for back and leg pain. Thirty-nine patients with a preoperative back pain score of 3 or less were identified. Propensity scoring was used to match these patients to patients with moderate back pain (NRS 4-6) and severe back pain (NRS 7-10) based on demographics, baseline health-related quality of life, and surgical characteristics, resulting in 35 patients in each group. Paired t tests were used to determine within-group differences, and analysis of variance was used to determine between-group differences. A statistically significant improvement occurred in ODI, SF-36 Physical Component Summary, and NRS leg pain scores from preoperatively to 2 years postoperatively (P<.0001) within all groups; and a statistically significant improvement occurred in back pain scores in the moderate and severe back pain groups. No statistically significant change occurred in back pain from preoperatively to 2 years postoperatively (P=.528) in the minimal back pain group. Patients undergoing lumbar fusion for predominant leg pain with minimal back pain had acceptable outcomes, with no increase in back pain postoperatively.

Cyst-ventricle stent as primary or salvage treatment for posterior fossa arachnoid cysts.

OBJECT: The optimal treatment of symptomatic posterior fossa arachnoid cysts is controversial. Current options include open or endoscopic resection, fenestration, or cyst-peritoneal shunt placement. There are potential drawbacks with all options. Previous authors have described stenting a cyst into the ventricular system for supratentorial lesions. The current authors have used a similar strategy for posterior fossa cysts. METHODS: The authors performed a retrospective review of 79 consecutive patients (1993-2010) with surgically treated intracranial arachnoid cysts. RESULTS: The authors identified 3 patients who underwent placement of a stent from a posterior fossa arachnoid cyst to a supratentorial ventricle. In 2 patients the stent construct consisted of a catheter placed into a posterior fossa arachnoid cyst and connecting to a lateral ventricle catheter. Both patients underwent stent placement as a salvage procedure after failure of open surgical fenestration. In the third patient a single-catheter cyst-ventricle stent was stereotactically placed. All 3 patients improved clinically. Two patients remained asymptomatic, with radiographic stability in a follow-up period of 1 and 5 years, respectively. The third patient experienced initial symptom resolution with a demonstrable reduction of intracystic pressure. However, he developed recurrent headaches after 2 years. CONCLUSIONS: Posterior fossa cyst-ventricle stenting offers the benefits of ease of surgical technique and a low morbidity rate. It may also potentially reduce the incidence of shunt-related headaches by equalizing the pressure between the posterior fossa and the supratentorial compartments. While fenestration is considered the first-line therapy for most symptomatic arachnoid cysts, the authors consider cyst-ventricle stenting to be a valuable additional strategy in treating these rare and often difficult lesions.